<form id="edit-form" class="form-horizontal" role="form" data-toggle="validator" method="POST" action="">

    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Presentation_drug_id')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-presentation_drug_id" data-rule="required" data-source="presentationdrug/index" class="form-control selectpage form-control" name="row[presentation_drug_id]" type="text" value="{$row.presentation_drug_id}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Reactions_events_assessed')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-reactions_events_assessed" class="form-control form-control" name="row[reactions_events_assessed]" type="text" value="{$row.reactions_events_assessed}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Administration_and_start_of_reaction_event_number')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-administration_and_start_of_reaction_event_number" class="form-control form-control" name="row[administration_and_start_of_reaction_event_number]" type="number" value="{$row.administration_and_start_of_reaction_event_number}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Administration_and_start_of_reaction_event_unit')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-administration_and_start_of_reaction_event_unit" class="form-control form-control" name="row[administration_and_start_of_reaction_event_unit]" type="text" value="{$row.administration_and_start_of_reaction_event_unit}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Reaction_event_number')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-reaction_event_number" class="form-control form-control" name="row[reaction_event_number]" type="number" value="{$row.reaction_event_number}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Reaction_event_unit')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-reaction_event_unit" class="form-control form-control" name="row[reaction_event_unit]" type="text" value="{$row.reaction_event_unit}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Did_reaction_recur_on_re_administration')}:</label>
        <div class="col-xs-12 col-sm-8">
                        
            <select  id="c-did_reaction_recur_on_re_administration" class="form-control selectpicker" name="row[did_reaction_recur_on_re_administration]">
                {foreach name="didReactionRecurOnre_administrationList" item="vo"}
                    <option value="{$key}" {in name="key" value="$row.did_reaction_recur_on_re_administration"}selected{/in}>{$vo}</option>
                {/foreach}
            </select>

        </div>
    </div>
    <div class="form-group layer-footer">
        <label class="control-label col-xs-12 col-sm-2"></label>
        <div class="col-xs-12 col-sm-8">
            <button type="submit" class="btn btn-success btn-embossed disabled">{:__('OK')}</button>
            <button type="reset" class="btn btn-default btn-embossed">{:__('Reset')}</button>
        </div>
    </div>
</form>
